Most doctors wouldn't want intensive care at the end of life

NEW YORK (Reuters Health) - Most doctors would not want
high-intensity treatment near the end of life, according to a
new study from Stanford University School of Medicine.

In 2013, researchers surveyed nearly 1,100 young doctors who
were finishing their training in a variety of medical
specialties. Nearly nine in 10 said they would choose a
do-not-resuscitate status near the end of life.

"We see too much in our practice and training when
high-intensity treatments actually hurt patients," says
Vyjeyanthi Periyakoil, a geriatrician who led the study.

She says she isn't surprised most physicians opt to die
gently, as they recognize "tipping points" when treatments
become ineffective. "We know when terminally ill, treatments
only help prolong the dying process, and there is no return on
your investment," she told Reuters Health.

Still, she and her coauthors say, what doctors want for
themselves and what they provide for patients is often at odds.

"More than 80 percent of patients say that they wish to
avoid hospitalizations and high intensity care at the
end-of-life, but their wishes are often overridden," the
researchers write in the open-access journal PLoS One.

The gap "is not likely due to patient and family choice,"
the authors contend. Instead, they say, it's largely due to
things like hospital size and doctors' practice style.

When the researchers compared their 2013 survey findings to
a survey done more than 20 years earlier, they found that
overall, doctors' opinions hadn't changed much over time.

The earlier survey was given to 790 community doctors in
Arkansas in 1989, one year before Congress passed the Patient
Self-Determination Act to require that health institutions ask
patients if they have advance directives.

The 1989 and 2013 groups had different opinions in only
three out of 14 areas. First, the modern doctors were more
likely to say they have greater confidence in their treatment
decisions if they're guided by a patient's advance directive.
They were also less worried about legal consequences of limiting
treatment when following an advance directive.

Finally, the modern group was less likely to believe that
widespread acceptance of advance directives would result in less
aggressive treatment even for people who didn't prepare such a
directive.

The researchers had hoped that the Patient
Self-Determination Act "would have resulted in a very positive
attitude change in doctors towards advance directives." Instead,
they say, the lack of a significant change in 11 of the 14 areas
they analyzed suggests "that much work needs to be done to
positively change doctors' attitudes towards advance
directives."

Periyakoil thinks the Patient Self-Determination Act fell
short.

"It did not mandate the system record what the patient
wants, archive it carefully, use it carefully and incorporate it
into the care plan," she said.

Congressman Sandy Levin (D-Michigan) authored the Patient
Self- Determination Act. "It was an educational effort to
empower people to make sure they had the information to exercise
their rights in very difficult moments," Levin told Reuters
Health. "I think it was an important step for patients in terms
of having control over their lives and the care they receive."

Pew Research shows that only one third of adults have
advance directives.

"I think as health care becomes more a part of American
life, the issue of advance directives will be less amenable to
controversy," Levin said.

Levin proposed a 2008 initiative to amend Medicare so that a
patient's first visit to a doctor for a physical exam would
include a discussion about advance directives. A measure to
reimburse doctors for facilitating discussions with Medicare
patients about end of life issues was dropped from early
versions of the Affordable Care Act after accusations among
political opponents it would establish "death panels." End of
life counseling is currently a voluntary physician service.

"What is billable, for example, and what doctors get paid
for is very different from what we would like them to do,"
Periyakoil said.

"We train doctors to do high-intensity procedures, and we
reward them for doing high-intensity procedures," she added.
"But we do not train or reward them for talking to patients to
(ask about) what matters most."